Time in the bank: A Stanford plan to save doctors from burnout

Dr. Greg Gilbert, emergency room physician at Stanford Hospital, conferring with colleagues. Gilbert is part of a program at Stanford that helps emergency room doctors lead more balanced lives (Photo by Chris Hardy/The Washington Post)

PALO ALTO, Calif. — It was just before noon on a recent Friday when Greg Gilbert, an emergency room physician at Stanford Hospital, made it home from another of what would be six overnight shifts in a row. Bleary-eyed and hungry, the divorced single dad was thinking about how to squeeze in a nap before it was time to pick up his three kids from his ex later that afternoon.

He spied a cardboard box from Blue Apron, which delivers all the makings of a home-cooked meal, and a black bag from the Munchery, with gourmet ready-made meals, waiting for him on his front porch and cracked a weary smile. They meant he’d have grilled flat iron steak salad for lunch, instead of his usual fast-food burger. And for dinner, he wouldn’t have to think of what to make or go to the grocery store but could just cook what was in the box and have time to play with the kids.

All of it is courtesy of the Stanford Department of Emergency Medicine. As was Gilbert’s freshly cleaned condo, the gift cards he’d given his assistant to thank her for her work, and the life coach he’s worked with to find better balance in his life.

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“This gives me more bandwidth at work,” Gilbert said. “And because I can hang out with my kids and not be exhausted all the time, I’m able to be the kind of parent I’d always hoped to be.”

The meals, housecleaning and a host of other services — babysitting, elder care, movie tickets, grant writing help, handyman services, dry cleaning pickup, speech training, Web support and more — are part of a groundbreaking new “time banking” program aimed to ease work-life conflicts for the emergency medicine faculty.

Doctors can “bank” the time they spend doing the often-unappreciated work of mentoring, serving on committees, covering colleagues’ shifts on short notice or deploying in emergencies, and earn credits to use for work or home-related services.

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The simple idea is aimed at addressing a complex challenge: Doctors, on average, work 10 hours more a week than other professionals, with nearly 40 percent working 60 hours or more, according to a 2012 study published in the Archives of Internal Medicine.

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It found that “an alarming” 1 in 2 physicians report at least one symptom of burnout and that they’re twice as dissatisfied with their work-life balance than those in other professions. Within 10 years of joining an academic medical faculty, 5 of every 10 doctors leave, and four leave academic medicine entirely.

And that is just as concerns about a coming physician shortage are reaching a fever pitch. The Association of American Medical Colleges projects a shortfall of as many as 90,000 physicians by 2025 as doctors retire, aging baby boomers need more care and mandates of the Affordable Care Act kick in.

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Stanford’s time bank, part of a two-year, $250,000 pilot funded largely by the Sloan Foundation, showed big increases in job satisfaction, work-life balance and collegiality, in addition to a greater number of research grants applied for and a higher approval rate than Stanford faculty not in the pilot.

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And for the first time, this year there are no openings for new fellows in the Department of Emergency Medicine. “All our spots have been retained,” Gilbert said. “There’s been no turnover.”

Stanford is not the only medical institution seeking to change an unforgiving culture that has traditionally rewarded long work hours. But most are aimed at medical students, where wellness programs are now required for accreditation. Johns Hopkins Medical School has instituted physical and emotional wellness programs for residents to prevent burnout, which has been linked to increased mistakes.

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Beyond burnout, Stanford’s time bank is also designed to help stave off the steep attrition rate of women in academic medicine and science. For the past two decades, a recent study found that women have made up about half of all medical school graduates. But they account for only 19 percent of medical school full professors and 11 percent of medical school deans.

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Time may be a big reason why.

Male and female faculty in academia tend to work the same number of hours, one analysis found. But men spend more time applying for grants and doing research, which lead to promotions and tenure. Studies show women faculty not only tend to do more housework and child care at home, but, at work, spend less time on research and more on teaching, mentoring and serving on committees, which contributes to the gender gap.

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By rewarding time spent on service work with time-bank credits, more men stepped up to do it, said Jennifer Raymond, a professor of neurobiology and associate dean who proposed the time bank and helped implement it. And more women were able to focus on their research by using time-bank credits to get help writing grants. And both men and women said using credits freed up time to spend with family.

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“In my mind, this program is brilliant, and maintaining it was an easy decision,” said Paul Auerbach, former chief of emergency medicine, who said the credits cost “far less” than 1 percent of his budget. “It’s extremely cost-effective.’’

The Department of Emergency Medicine’s time-banking program is currently all that’s left of the more ambitious pilot project. Other divisions are “waiting to see” how the program goes and whether the university will allocate funding for administrative costs, said Magali Fassiotto of the Office of Faculty Development and Diversity, who has been monitoring the time-bank program. “There is quite a bit of interest, though.”

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Hannah Valantine, a cardiologist who led the pilot at Stanford, said work-life struggles are still often seen as a side issue in medicine. “The whole idea of addressing work-life fit as an important business case for excellence has not been bought into yet,” she said. “And I would argue that it should be right up there.”

The view that work-life issues have little place in medical culture is a strong one. Auerbach and others say that when they were starting out the mantra was “Work more. Live less.” The decision in 2003 to cap residents’ workweeks to 80 hours and to limit first-year resident shifts to 16 hours continues to stir debate. Some doctors argue that less-exhausted residents give better patient care and make fewer mistakes. Others worry that young doctors won’t see as many patients with a variety of conditions, leaving them less skilled.

Karen Sibert, an anesthesiologist and mother of four, sparked a firestorm when she wrote a New York Times opinion piece in 2011, criticizing work-life balance in the medical field. “I think it’s fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether,” she wrote. “It’s different for doctors. Someone needs to take care of the patients.”

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Yet Mark Linzer, who has studied physician burnout for 20 years, said that when burnout rates hit 50 percent a few years ago, medical institutions began paying attention to work-home conflict. Early on, he’d be asked to present his data once or twice a year on the epidemic of physician burnout and how to turn it around. Now he may get one or two requests a day.

“All these institutions think they have to do big, bold, expensive projects,” said Linzer, director of General Internal Medicine at Hennepin County Medical Center in Minneapolis. “But bold doesn’t mean expensive. It just means pay attention to what people are saying. Listen. Do something special. Then measure how you did.”

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Indeed, a group of top doctors at Stanford is proposing that the school fund a center dedicated to changing the “Iron Man” culture of medicine.

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“When a physician drops off the precipice because they’re overstressed, the amount of damage it does to the medical care system is tremendous,” said Bryan Bohman, a professor of anesthesiology.

Sitting in his immaculate kitchen and happily munching on his microwaved steak salad, Greg Gilbert said he once left academic medicine because of work-life conflict.

“I was definitely starting to feel burned out before the program,” said Gilbert, 43. He says the stress of long work hours had strained his former marriage.

Physicians like Gilbert can certainly afford to pay for time-banking services like these on their own, but they’re often too busy to find them, he said. And Stanford could give people raises to cover the cost. But, he and others said, the very fact that the institution is running the time-banking program is why it works.

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“A lot of times you feel that work doesn’t care about you. ‘I’m just doing the grind, and for what? I’m missing out on my family and my life.’ And this program really sets that opinion on its ear,” Gilbert said.

The program got its start when a former medical school dean, Phillip Pizzo, grew concerned that so many talented female doctors, including his own daughter, were foregoing promising research and other career avenues in order to juggle family demands.

He set up a task force. An analysis found that the school had virtually every “family friendly” policy on the books imaginable — paid parental leave, sabbaticals, options for flexible scheduling, good benefits for part-time work and more. The problem: No one was using them.

Unsure what to do, the task force hired an innovative design firm, Jump Associates. Like anthropologists, they trailed doctors with video cameras, interviewed staff and made field notes. They concluded the policies violated the core culture at Stanford: that excellent work required all-out work devotion, all the time.

“The physicians and scientists feared that if they used the policies, they’d be viewed as not being serious about their careers and would suffer as a consequence,” said Valantine, who is now chief officer for scientific workforce diversity at the National Institutes of Health.

The pilot involving about 60 men and women in the basic sciences and five clinical medicine departments was an effort to change that perception. It offered career planning sessions to “normalize” flexible schedules and alternate career paths, and created the time bank.

Tom Clandinin, a professor of neurobiology, said at first he used his credits from serving on more than 25 student committees only to “buy” help writing grants — which enabled him to apply for and win more to fund his lab where he studies how the brain computes. Once his second child was born, he began using his credits to buy home-delivered meals for him and his wife, who is also a doctor, which he called “enormously helpful.”

Merritt Maduke, a professor of molecular and cellular physiology and mother of one, used her credits to get help filling out grant applications and putting bibliographies together, so she could focus on her research.

“Not doing that routine work freed up time to talk to my colleagues, to think,” she said. “As a result, I got two research grants. Everyone loved this program. I’m still grieving the loss.”

Preliminary results of the pilot show that a vast majority of the physicians and scientists felt they’d improved their work-life fit, and the share who said they were satisfied at Stanford increased by nearly 60 percent, Valantine said.

Pilot participants submitted 22 grant proposals with the help of time-bank credits. Forty-one percent were approved, for a total of $10 million, a higher success rate than for the general Stanford population.

Volunteering to cover shifts on short notice nearly doubled, to 83 percent, and people reported feeling more collegiality. Fewer postponed or avoided taking care of their health or put off vacation. The proportion of faculty who had time to discuss science with their colleagues jumped from 9 to 55 percent. And the share of female faculty members who felt Stanford supported their career development rose from 29 to 57 percent.

“That’s superbly promising. And we’re not talking about changing the metrics of success, lowering standards or diminishing excellence,” Valantine said. “We’re talking about how we get greater excellence by paying attention to work-life issues.”